Summary
 

Identifies, researches, and investigates providers for aberrant and abusive billing practices against the company and its subsidiaries. Analyzes hospital accounting records and credit reports for overpayments and fraudulent billing to the corporation.

Description
 

Location: This position is full-time (40-hours/week) Monday-Friday in a typical office environment. You will work an 8-hour shift scheduled during our normal business hours of 8:00AM-5:00PM. It may be necessary, given the business need to work occasional overtime. You may be required to travel between buildings. This role is located at 17 Technology Circle, Columbia, SC 29203.

• SCA Benefit Requirements: BlueCross BlueShield of South Carolina and its subsidiary companies have contracts with the federal government subject to the Service Contract Act (SCA). Under the McNamara-O'Hara Service Contract Act (SCA), employees cannot opt out of health benefits. Employees will receive supplemental pay until they are enrolled in health benefits 28 days after the hire date.

What You’ll Do:

• Conduct onsite audits of hospitals and provider facilities to identify overpayments and compliance with government regulations, which may include Medicare Secondary Payer (MSP) regulations.

• Analyze provider contracts to determine the proper reimbursement of inpatient and outpatient benefit payments and calculates correct refunds.

• Perform comprehensive review and responds to complex inquiries of all varieties of provider facilities. This may include the review, trending, analysis, and executive report of all claims actions.

• Identify potential fraud and abuse situations and refers documented findings to appropriate area for investigation.

• Develop comprehensive financial strategies and master audit programs for hospitals and provider reviews.

• Conduct outreach workshops and training sessions for appropriate groups to focus on problem areas relating to government regulations and billing issues.

• May coordinate research and reporting functions for the MSP prepay claims department.

To Qualify For This Position, You'll Need The Following:

• Required Education: Bachelor’s Degree in a job related field.

• Degree Equivalency: Degree Equivalency not applicable for the Celerian Group, Bachelor’s degree required.

• Required Experience: 3 years-healthcare/hospital management. 3 years-claims analysis/adjudication procedures, trending, or patterns of practices. (may be concurrent).

• Required Skills and Abilities:

  • Analyzes provider contracts

  • Conducts provider compliance audits

  • Identifies potential fraud situations

  • Makes recommendations for corrective actions

  • Produces monthly summary reports.

We Prefer That You Have The Following:

• Experience writing Audit reports.

• Medicare Claims Knowledge.

• Ability to read Remits and EOBs.

• Ability to hold conference calls with Senior Management both internally and externally.

• Ability to interpret and understand MSP requirements as they are found in the CMS IOMs.

Our Comprehensive Benefits Package Includes The Following:

We offer our employees great benefits and rewards.  You will be eligible to participate in the benefits the first of the month following 28 days of employment.  

• Subsidized health plans, dental and vision coverage

• 401k retirement savings plan with company match

• Life Insurance

• Paid Time Off (PTO)

• On-site cafeterias and fitness centers in major locations

• Education Assistance

• Service Recognition

• National discounts to movies, theaters, zoos, theme parks and more

What We Can Do for You:

We understand the value of a diverse and inclusive workplace and strive to be an employer where employees across all spectrums have the opportunity to develop their skills, advance their careers and contribute their unique abilities to the growth of our company.

What To Expect Next:

After submitting your application, our recruiting team members will review your resume to ensure you meet the qualifications. This may include a brief telephone interview or email communication with our recruiter to verify resume specifics and salary requirements.

Equal Employment Opportunity Statement

BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains affirmative action programs to promote employment opportunities for individuals with disabilities and protected veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.

We are committed to working with and providing reasonable accommodations to individuals with disabilities, pregnant individuals, individuals with pregnancy-related conditions, and individuals needing accommodations for sincerely held religious beliefs, provided that those accommodations do not impose an undue hardship on the Company.

If you need special assistance or an accommodation while seeking employment, please email mycareer.help@bcbssc.com or call 800-288-2227, ext. 47480 with the nature of your request. We will make a determination regarding your request for reasonable accommodation on a case-by-case basis.

We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Here's more information.

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